Project Summary Abstract Despite recent advances in treatment, 30-40% of patients with acute lung injury (ALI) do not survive. Three decades of research on end-of-life care in the United States indicates that Americans dying in intensive care units often spend their final days receiving life sustaining treatment they would not choose. One reason for this is that family who are acting as surrogate decision-makers frequently do not understand how poor a patient's prognosis is. This problem has negative effects on both patient-centered care at the end-of-life and also on effective use of health care resources. Unfortunately, no empirical studies have addressed what disclosure strategies effectively convey news of a poor prognosis to family of critically ill patients. The long-term goal of this research program is to improve decision-making and communication about prognosis for patients with acute respiratory failure at high risk of death or severe functional impairment through the development and testing of evidence-based interventions. In the proposed research, we address 3 critical gaps in knowledge that limit our ability to develop such interventions. Aim 1: to identify disclosure strategies that effectively convey prognostic information to family of critically ill patients. Aim 2: to determine the extent to which families' misperceptions about prognosis are associated with prolonged use of life-sustaining treatments before death. Aim 3: to determine physicians' and families' perceptions about how prognosis should be communicated in the setting of critical illness, and the barriers to changing physicians' behavior in this regard. We will use the infrastructure of the ARDS Clinical Research Network to conduct a prospective cohort study of communication about prognosis for 175 patients with acute respiratory failure from ALI. We will audiotape physician-family conferences and quantitatively code how physicians disclose prognosis. We will elicit quantitative prognostic estimates from physicians and families after these conferences, and use multivariate methods to identify strategies that effectively convey prognostic information. We will conduct semi-structured interviews with 30 physicians and 60 family members regarding strategies to disclose news of a poor prognosis. The research is significant because it will provide new information about effective and acceptable methods to communicate about prognosis as well as an estimate of the extent to which poor communication about prognosis is associated with more use of life-sustaining treatment. This research is innovative because we will combine quantitative and qualitative methods, new measurement tools developed by our group, and a multidisciplinary research team to study communication about prognosis. These insights will allow us to develop a targeted intervention to improve the care of patients with acute respiratory failure. Project Narrative Twenty percent of deaths in the US occur in or shortly after a stay in an intensive care unit (ICU), a setting in which highly technological, expensive care is delivered. Families are often asked to participate in decisions about whether to continue life-sustaining treatment, but many families experience inadequate communication with clinicians and do not understand the patient's prognosis, making these decisions difficult. The results of the proposed study will provide information about effective and acceptable strategies to disclose news of a poor prognosis to family members of critically ill patients. These insights will allow us to develop an intervention to improve communication about prognosis for patients with acute respiratory failure.